It's a horrible awful place. I should know. I work there.

The state government is cashed up on stamp duty from the housing boom - budget of $20 billion, wasn't it? It's their responsibility to ensure that hospitals are adequately resourced that this type of thing doesn't happen. Instead, they play games of double dipping with Federal funding sources, and deplete the hospitals so badly, while spending money on sports stadiums and goodness knows what.

I actually do respect Jill Hennessy very much, and think she's a good health minister, but this is on her watch, and on the conscience of Western Health. There are deep seated fundamental systemic issues of governance there, which are at the heart of tragedies like these.

Until the health managers start to listen to their senior medical staff, and leave their ivory towers, things like this will happen. I do think that the new medical director will improve things there though.